Treating the ‘Alcohol’ in Alcohol-Related Liver Disease - PowerPoint Presentation

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Treating the ‘Alcohol’ in Alcohol-Related Liver Disease

Jessica L. Mellinger MD MScAssistant ProfessorDivision of Gastroenterology

Anne C. Fernandez PhD

Assistant ProfessorDepartment of Psychiatry

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Disclosures

With respect to the following presentation, there has been no relevant (direct or indirect) financial relationship between the parties listed above (and/or spouse/partner) and any for-profit company which could be considered a conflict of interest.Funding: Dr. Fernandez is supported by a K23 career development award from NIAAA

Dr. Mellinger is supported by a K23 career development award from NIAAA

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Topics Covered

The context of alcohol use disorder (AUD) within alcohol-related liver disease (ALD)

How treatment of ALD patients often differs from other patients with AUDThe importance of Multidisciplinary careOur team’s approach to multidisciplinary AUD/ALD treatment

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Defining Drinking: How Much is Too Much?

“Healthy”

Use

Up to 1 drink/day for women, 2 drinks/day for menBinge drinking>= 5 standard drinks for men, >=4 standard drinks for women on single occasionHeavy alcohol useBinge drinking on 5 or more days in the past monthAlcohol use disorderOnce you have alcohol-related liver disease, any alcohol use is risky

“Dietary Guidelines for Americans: 2015-2020” Dept of Health & Human Services and Dept of Agriculture. Kranzler HR & Soyka M, JAMA 2018;320(8)

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Alcohol use in ALD patients

Advanced forms of liver disease develop after very heavy, regular alcohol use often over the course of years (or decades)

With some exceptions (e.g. genetic predispositions) these patients almost certainly have severe, alcohol use disorder (e.g. alcohol dependence) or moderate, alcohol use disorder. This is a chronic relapsing condition, that can be managed but not ‘cured.’

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Our first 51 patients AUD diagnoses

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Comorbid Substance Use Disorders are High

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Mental health comorbidities are also high

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How ALD Patients Differ from General AUD Patients

Decision to stop drinking thrust upon them by medical eventMedical health a priority (not psych health)

Don’t perceive need for treatmentPreoccupied with medical/transplant management

Don’t think they have an addiction problemAre not addiction treatment seeking*Courtesy of Andrea DiMartini MD (U Pittsburgh)

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S

tages of change “reverse”

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The importance of multidisciplinary care

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Referral to AUD treatment isn’t always so easy….

Wide geographic distances

Paucity of psych providersRural = sparseInsurance coverageSaturated w/ severe ptsSober ALD pts “too well”

↑↑ med-psych complexity↓ ALD expertise in community colleagues

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Multidisciplinary care

Multidisciplinary, integrated SUD treatment models are key to caring for patients with complex diseases influenced by behavior, physical health, and mental health.Hepatitis CHIV/AIDSOrgan transplantDiabetesAlcohol-related liver disease

Winder GS, Fernandez A, Klevering K, Mellinger

JL. Psychosomatics. 2019 Dec 19.

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Medical silos in a health system

Discipline A

Discipline B

Discipline CDiscipline DDiscipline ECOMPLEX DISEASE X

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Bring the team to the patient

Cross-training, robust collaboration, strong relationships, regular meetings

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Literature on integrated SUD care

16

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MAIN ALD Clinic Structure

Patient

Hepatology

Psychiatry

Addiction Psychology

Social Work

Nursing

Every other Monday

3 NPs + RVs

Pre-clinic phone call (SW)

In-clinic ALD Education Packet with RN review

See

hepatology

, psychiatry, either psychology or SW

Tox

screens each visit and in-between

Commitment to 3 MET/CBT sessions with clinic staff

1

st

Year: 51 patients Outcomes: Liver, AUD, Cost/Value

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Why multidisciplinary could help AI/AN populations

Native Americans/Alaska Natives are more likely to need alcohol or illicit drug use treatment than persons of any other ethnic group (not due to highest overall use, but highest severe use). The Substance Abuse and Mental Health Services Administration reports that 13% of Native Americans need substance use treatment, but only 3.5% actually receive any treatment.

Substance Abuse and Mental Health Services Administration. (2019). 

2018 National Survey on Drug Use and Health Detailed Tables.Dickerson, D.L., Spear, S., Marinelli-Casey, P., Rawson, R., Li, L., & Hser, YI. (2011). American Indians/Alaska Natives and Substance Abuse Treatment Outcomes: Positive Signs and Continuing Challenges. Journal of Addictive Diseases, 30(1), 63–74.

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AI/AN populations may have face more treatment barriers

Some treatment barriers disproportionately influence AI/NA communities

Lack of treatment resources in rural areasLack of insuranceLack of transportationAccess to telehealth??Less access to evidence-based treatmentsLack of culturally-appropriate treatment services that recognize NA/AI identity and the diversity within NA/AI communities and tribes

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For additional information…

https://www-sciencedirect-com.proxy.lib.umich.edu/science/article/pii/S0740547215300866?via%3Dihub

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Goals of Multidisciplinary Care

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Relationship Building:

Between Visit TouchesPre visit calls to orient them to the clinic visit, answer questions, and trouble shoot for barriers to attending.After visit calls to ask about medication compliance and to make sure follow up appointments are scheduled, resources have been provided, and answer any questions.Between visit calls to check in and follow up.

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ALD Clinic Educational Materials

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Social Worker trained in Addictions and Case Management

Has clinical training and experience in treating patients with Substance Use DisordersWorks on identifying and reducing barriers to care for patientsKnows resources and can make referrals

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Motivational Interviewing

The Spirit of MI - communicating compassion, acceptance, partnership, and respect - sets the tone for the interview with these complex and challenging patients.Recognizing that ambivalence is normal, even expected, with this population.Emphasizes the power of choice, as this population feels they have lost this with their diagnosis.Framework for providing information about treatment

with the patient’s permission, rather than putting it upon them as it may have been by previous providers.

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Individual Therapy Visits

We ask all patients to participate in 3 sessions of therapy with the Psychologist or Social Worker in the clinic.Many patients have not engaged in therapy before, or had bad experiences. This opens that door for these individuals can commit to.Gives us the chance to get to know the patient better, provide psychoeducuational, find out what motivates them, and to refer them to appropriate resources in their area.Many patients live far away, these visits can be scheduled

as telehealth visits (now that this is approved by insurance)

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Referrals for TreatmentMany of our patients live over an hour away from our clinic.

Each Health Insurance plan determines what kind of treatment and where the patient can get treatment. Medicaid/Medicaid HMO patients have limited options.Our clinic can only provide outpatient, time-limited careTreatment resources are scarce.

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American Indian/Alaska Native AUD treatment resources

Wellbriety :

www.wellbriety.comIndian Health Service – alcohol and substance abuse programs www.ihs.gov/asapAA for Native Americans www.naigso-aa.orgPromising practices to reduce alcohol and substance use among AI/NA individuals

http://wellbriety.com/wellbriety/wp-content/uploads/2019/06/Promising-Practices-Strategies-Reduce-Alcohol-Substance-Abuse.pdf

Supporting sobriety among AI and NA: a literature review uihi.org/wp-content/uploads/2014/02/Supporting-Sobriety_A-Literature-Review_WEB.pdf

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The

hepatolgist (or PCP) will bring patients in… (honey), so link the psych visitsUse between clinic ‘touches’Start with a small “ask”Make clinic appointment policies clear and concrete

Warm hand-offs“ambush psychiatry”Creativity and Persistence

Scott Anne Kristin

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Take-awaysSeverity of AUD and psychiatric comorbidities is

high in ALD patientsTheir needs are complex and not well-served in one clinic visit with one provider typeThere is a need for multidisciplinary care AUD/ALD patientsMost patients DO come to initial mental health visits,

some engage in more intensive treatment, and some stop drinking!AUD treatment engagement and alcohol cessation in this population is a huge challenge that requires creativity, persistence, patience, and relies heavily on “the heroism of incremental care.”

Gawande (2017) The Heroism of Incremental Care, The New Yorker

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Questions